A RESPONSE: MY VIEWS AROUND CURRENT BARRIERS IN DUAL DIAGNOSES.

Firstly to qualify me for being in a position to input on this subject. I have been involved in drug user advocacy and substance use research on many different levels,  including dual diagnoses, which occurs in a high number of those accessing support through services and mutual aid groups. My role in the field is to add a realistic voice to an often idealistic approach in dealing with and supporting those with multiple disorders and reduce the risks and harm to those living with various conditions including pre-treatment, treatment, aftercare, stigma and various other issues that arise during the care of those I come in contact with. I am lucky enough to be employed in the drug and alcohol sector in UK and also dedicate a lot of my personal time to researching and supporting those living with conditions within our communities.  I would like to also take the chance to thank Louise Rugman for her input and research in this topic and for her ongoing support with regards to the support and care of those living with dual diagnoses, homelessness, and a number of other related issues,  despite her living with an ongoing condition herself. An inspiration by all accounts whose input into my response was valued and informative.

Many thanks Opi Ferum our Australian connection for the thought provoking questions.

1: How do you see people who use substances first-hand living with a mental health issue being treated in the current field of alcohol and other substance care? Do you see harm reduction practices being practiced or not?

With a basic understanding of a number of co-morbid conditions, I’d agree that there has to be first and foremost an element of reducing the risks and harms in this line of care. A number of mental health conditions are not curable, and are indeed long term, and therefore the emphasis needs to be on reducing the harm to the individual and their significant others with regards to minimising the symptoms of the condition and various other aspects of the condition. Harm Reduction  focuses on the minimisation of the physical, social and legal harms, primarily, of those who are living with any kind of condition or disorder among other aspects of care. However, when there is an underlying element of substance use running alongside the condition, which realistically there often is. This can cause controversy with regards to the continuing care for an individual if not addressed and implemented correctly, which unfortunately seems to be all too common. I agree that some form of development orientated practice must also be administered into the care but wholeheartedly feel that the basis of any care, and throughcare,  especially when dealing with dual diagnoses needs to be firmly rooted in reducing harm and minimising risk to the individual whose care is priority and this should be carried right through the journey of that individual, and, those surrounding that same individual without prejudice or discrimination for the use of substances restricting ongoing support.

Harm reduction primarily deals with reducing the consequences of high risk behaviour and sets out to improve the positive outcomes of an individual with regards to supporting them to get the best out of their current situation regardless of their condition. An ideal model of care that I would suggest would be, first and foremost establishing a solid rapport with an individual who is currently living with dual diagnoses, this is imperative with regards to the continued care of that individual. There are a number of benefits here with regards to mutual aid being an integral part of the care of an individual with regards to the concept of an ‘expert by experience’, however due to the nature of the condition there is an obvious need for more comprehensive care and attention, there are agencies that operate a buddy system, whereby the peer support can be advocated for throughout the whole journey of the individuals care. This has proven to be quite effective where practiced. Establishing the cost benefit ratio of continued use and the possible effects when engaging in risky behaviour of any type associated with the condition can be a positive aspect of engagement, however this is not always paramount in an individuals mind when having an episode, for instance, but, it does serve as a positive piece of work with regards to raising awareness around pro’s and con’s of continued use and perhaps preparing a proposed care plan to support specific situations once triggers are recognised. Relapse prevention and setting individual goals for change are again an imperative topic for discussion with regards to an individual’s care. Discussing possible coping mechanisms for any given situation and looking at how to deal with crisis as and when it arises. Mutual aid forums and positive social network interaction again is something I advocate for with a passion, right through an individual’s care and beyond.

So, do I see this working effectively in services designed to care for and support individuals with co-existing conditions. Yes, I do see this happening, but not as often as I would like to…sadly there seems to be a lack in partnership working to fully support an individual living with dual diagnoses.  Also another take on this from an individual who has accessed service for dual diagnoses is that there is an element of confusion with regards to the message being delivered on interventions. Her view was that harm reduction was openly advocated for and promoted within the mental health support service, however, most of the therapies demanded abstinence? One specific report that I have been given in a number of feedback scenarios is access to Dialectic Behavioural Therapy. This is now being highlighted as a therapy that could be used in drug and alcohol services but until then is primarily given as a therapy via mental health services and complex needs teams. This however along with a number of other therapies that are specifically aimed at promoting wellbeing within the sector ‘demand’ abstinence, even from prescribed OST, and therefore there are a number of dual diagnoses individuals who will not be able to access a number of therapeutic treatment options. This in turn excludes a number of individuals with dual diagnoses from entering effective therapeutic alliances with supportive structured therapy options until not only have they moved away from their substance use, but, also way from their OST as well, I have met a few who have been put in the unrealistic situation where they are being ‘pressured’ to implement rapid reduction detoxes to continue their care, or face closure until such times as this is achieved.  Therefore by my reckoning, the tools needed to promote well being are not always fully available, and further to that are not accepting of the fact that there are those who may relapse during the therapy, due to stress and a number of other contributing factors. This unfortunate situation has arisen a number of times both in my personal life and also in my professional capacity where there has been an almost non-existing care plan offered from mental health services dealing with dual diagnoses other than a demand for abstinence when referring in for support for substance use, or, completely the opposite, an extremely comprehensive care plan that cannot be put into action until abstinence is achieved, putting undue stress on the individual going through the process.   Now although I understand that there are a number of reasons why abstinence would be suggested, the main one being it is hard to diagnose an individual who is currently taking a substance which could possibly alter the chemicals in the brain to a point that a correct diagnosis may not be reached immediately, which could cause further distress with the individual, also the fact that substance use on top may not be as effective when using illicit substances on top. However, this becomes a catch 22 situation if an individual is self medicating and presenting with dual diagnoses. If there is no structured joint work between substance misuse services and mental health services and this demand for entire abstinence becomes a barrier to dual support for a dual diagnoses, then, this in my opinion leaves a wide opening for lack of persistent and consistent care and promotes a support network that is fraught with holes. Which are all too easy for those seeking care to fall through.

So to summarize yes I do see harm reduction initiatives working well in Mental health services but there is room for improvement and a more responsive and productive alliance with other services and also within service, to reduce the stress for an individual in the system, by promoting clear and direct access to consistent therapies designed to reduce the risk, without unrealistic ‘requirements’ being imposed or exclusion for substance use, especially substitute medications therapy.

2: How do you personally see harm reduction as a sensible approach to dealing with substance use and mental health? After all, a lot of people that use substances are co-morbid in diagnoses.

I see harm reduction as being of maximum importance when dealing with those living with co-morbid issues in this context. Firstly, as I have stated there are a number of dual diagnoses individuals that have conditions that are ongoing and require ongoing assistance and intense support. Mental illness is not something that can be taken lightly and most definitely not something than can be covered with a blanket policy under the abstinence banner. There are a number of diagnoses that until science and research moves forward, which it does on a daily basis, are constant and require consistent reviews at any particular time to reduce the risk and harm to the individual and those surrounding the individual, as mental health and substance use  can also be a strain on family and significant others, which needs to be, and indeed is, focused on harm reduction with a view to supporting all involved to achieve the best out of a current situation or occurrence, or general well being.

With bipolar disorder for instance there are a number of contributing factors that require a solid and comprehensive approach based in the harm reduction ethos. This is a condition that presents itself with a number of reasons that support harm reduction due to the nature of the condition. Although there are major concerns that would advocate for the abstinence route, and this should at all times be the desired goal, it is not always as clear cut as it may appear. Bipolar and substance use go hand in hand, and, this condition is one of the more prominent that I have come in contact with, with regards to dual diagnoses. Yet as I have said before, a lot of the proposed therapies that are designed to support an individual with this particular diagnoses are aimed at those who are abstinent? Therefore, putting a major barrier up for those who are living with similar conditions, rather than, supporting and offering alternative therapy,  to increase chances of any positive steps towards recovery, by definition, from certain aspects of the condition.

The duty of a substance misuse support agency is primarily to deal with the substance side of dual diagnoses and with all the best intentions it is not really common that you come across a practitioner that is equally qualified in both sides of this coin, this being said, as a practitioner in the substance misuse field when I am dealing with those with current and historic dual diagnoses I am constantly advocating for joint, partnership working for the better outcome and not always successful in this due to unrealistic requirements for continued care and support, which is not ideal in supporting an individual through the process.  Although I have no doubt there are a number of highly trained individuals out there who do have a full understanding of both sides (I unfortunately am not one)  Therefore, they would primarily be dealing with the substance and all it’s related issues. However, once a certain level of reduction in substance use is reached there is the risk of relapse due to the mental health condition taking prevalence, especially if the individual has been using a substance to self medicate? This is where I feel the abstinence call from mental health services gets taken out of context and should be re-evaluated with regards to a demand for abstinence, amongst other things. And this is again where a number of those with dual diagnoses end up falling through the net through lack of joint working between services, or unrealistic requirements being set out prior to continuation of care.

Harm reduction in the role from the substance misuse angle provides a solid safety net for those who are going through the mental health service support network and may fall through the net for a number of reasons. That being said harm reduction drug and alcohol services are not an alternative or as I have heard it affectionately called a ‘dumping ground’  for those who structured support within the mental health service is proving to be partially unresponsive. It is a complimentary support service to run alongside the already existing support network yet all too often seems to be seen as a completely separate service prior to mental health service engagement.

Another issue that rears it’s ugly head here in this arena is the fact that there were a number of services set up to deliver specific services based in dual diagnoses, exclusively,  but due to the payments by results scheme, which has been a roaring success?? the services which were aimed specifically at this field were not seen to be a financially secure ‘investment’  in that the outcomes of ‘complete’ recovery as a dual diagnoses outcome is not always achievable in this particular arena. Thus putting pressure on the relevant services to enforce policies and procedures that are not truly reflective of the individual needs. There is clear and professional guidance for mental health services to promote joint or collaborative working relationships for the due care and attention of an individual that presents with dual diagnoses, however, those services are now commissioned based on a recovery model that given the nature of the condition is unrealistic to uphold without ‘enforcing’ specific requirements, one of which unfortunately is the abstinence ‘need’ for therapy in certain cases. Herein lay the dilemma where if an individual is not currently abstinent or not seen as being someone who can achieve abstinence, in a specified timescale, they then become a burden on service that has targets to meet in order to secure it’s funding for the next year. Harsh but sadly the truth. Hence the lack of joint working or restricted joint working until abstinence is achieved. Verging on Nimby-ism?… possibly!

3: How do you feel a mental health diagnoses affects a person that uses substances? Do you feel it puts them in a position whereby their drug use overshadows their mental health, for example? Or the opposite? Or don’t you think it makes any difference?

I think that a mental health diagnoses can be a lot to deal with for an individual, but at the same time can be a relief due to there actually being a basis for otherwise unexplained episodes during the individual’s life. Whatever the outcome following a diagnosis there is without doubt an element of stress, confusion, fear, and a number of other contributing factors that could put an individual at added risk. Its not every day that you are given a diagnosis that could have a major effect not only you but on every other aspect of your life and those involved in your life.

This can have quite an effect on an individual. And in turn on their substance use, if this is a co-occuring trend in that individual. I wouldn’t say that it doesn’t make any difference as it most definitely would. The effect however would depend massively on the individual. Neither ‘should’ overshadow the other as both are issues that overlap in a number of ways and both are relevant in the progress of the other, however, I can see how one could take prevalence over the other at any given time during the individual’s journey. Another reason for comprehensive dual support.

Again relaying from a discussion around this with my partner, who has been through this situation. When given a diagnosis, although there was a sense of relief that went alongside it there was also understandably a sense of overwhelming fear and lack of understanding that came with the diagnosis which resulted in her pulling away from services for a period of time to digest the information, an obvious reaction in a situation of this magnitude, however…..this highlights a concern, in that, this is obviously a testing, scary period and quite a vulnerable situation for an individual, yet with the facts being presented to the relevant services, she was then able to ‘disappear under the radar’ for a number of years without due care and attention being given to support the news given. Surely there is a duty of care here with regards to this? Or am I mistaken in believing that this may be a regular occurrence that repeats itself in similar situations, which, given the serious risky behaviour (a recognised trait) that could follow, could put an individual in the red on the RAG system, (high risk to self or others) and in a precarious situation. Here I have to ask, how is it possible for someone to effectively disappear, and in all honesty, be able to disappear without being subject to some kind of preventative measure being taken to ensure minimal risk to the individual after being given news of this kind? However, once resurfacing the first place she accessed was the substance misuse service for support as it was made  clear on her first access in treatment, where she was diagnosed with her condition, that her substance use would have to be dealt with prior to her mental health issues being effectively addressed?

There are a number of research papers and debates surrounding dual diagnosis that are almost reminiscent of the chicken and egg scenario, however this seems small in comparison to the fact that there is an individual presenting with a need for immediate support regardless of what came first. Surely? This would transpire during care within a systematic approach that involves substance use and mental health services joint working for the better towards an outcome that promotes well being for the individual.

I must also add here that there is a massive responsibility here on the way news of this nature is delivered to an individual and also how it is seen to be supported in follow on care. Both sides of the care spectrum here are of equal value in promoting the best outcomes for an individual when on the outside devising further care plan. however as I have said there will be different responses from every individual who finds themselves in this situation. And each individual response should then be taken into account with regards to next steps with the care of that individual encompassing all avenues of care equally and with dual importance inclusively.

If one is left to put more emphasis on the other then I fear that the evidence would create a never ending circular effect rather than one of positive steps forward towards any positive definition of recovery.

4:  How would you like to see services engage with people that use substances with a co-existing mental health issue…for example…would you like to see more advocacy for mental health issues within the alcohol and other drug community? Are more services needed? If so. can you think of any in particular?

Collaboratively? There seems to be a distinct barrier towards supporting individuals with dual diagnoses and other co-existing conditions. And  trend for ‘either or’ support. Not totally, I might add,  but it does exist and it is quite frustrating to a professional trying to wade through the paperwork and the requirements and the target setting etc, etc, to meet specific requirements set out to ensure continuity of  care. So, that being said, is it any wonder there is a high rate of drop out in dual diagnosis recovery statistics. There is also the existing and very relevant social inequalities issue around differing support and care that also adds a little spice to the state of play. Another issue worthy of debate on another platform, social, economical, environmental, etc….

With regards to advocacy within substance misuse services I feel that there is always room for more advocacy for something of this magnitude which is of high importance and can be severely detrimental to an individual if they are not given an all inclusive support package to coincide with the delivery of a diagnoses. Having said that I am fortunate to be able to say that, in my experience, there has always been a frontline approach within substance misuse services towards mental health issues in ensuring there is full support and wrap around service engagement when dealing with dual diagnoses at every level, within remit. I do think that there could be more peer support and support groups put in place on the mutual aid front to support individuals living with dual diagnoses. And that this is something that is possibly being overlooked in the current abstentionist movement. Because of the high risk of relapse in thoughts feelings and behaviours, as well as substance use, however, this is where harm reduction is all inclusive in it’s outlook to promoting ‘full’ recovery and supporting those for who ‘full’’ recovery may not be possible, in every aspect of their lives. It supports the individual to achieve a full and positive outcome regardless and also to achieve acceptance both personally and within their respective communities regardless, without putting unrealistic targets, requirements and aspirations on them at the same time.

With regards to services, it is unfortunate that there were services out there that were primarily set up to deal with dual diagnoses, but as mentioned previously they are being systematically dispersed due to cuts, and, being in the unfortunate position of not meeting current payments by results criteria. A sad state of affairs where an already stigmatised group of people are now being restricted in care options because of financial and economic distress. The negative impact this could have on an individual seems to have been lost in a quagmire of finance and social cleansing. Perhaps if we were to challenge that brilliant marketing tool for big pharmaceutical companies, the DSM, and bring it back to individual care rather than profit then there would be more realistic and less idealistic approaches and more funding to put into supporting these individuals rather than paying out extortionate fees for excessive over prescribing of medication.

More services are always needed to cover dual diagnoses, in my opinion, however a re-assessment of those already existing services that are involved in the care and attention of those with dual diagnoses would serve purpose for the time being in a climate of ‘more for less’ at the cost of less intense care and support for the individual at the heart of it all . And a more open and inclusive approach to dealing with and supporting those who are living with co-morbid conditions which includes more support groups aimed at peer support and mutual aid and more public understanding of the realities of dual diagnoses.

It would appear that there is a flaw in the current recovery agenda that does not take into consideration those for whom ‘full’ recovery may not be possible, and with current financial cuts hitting the sector hard where it is most effective, and indeed most needed, the safety nets are being dismantled and taken away from the providers that cater for those who are caught in the middle.

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